A coroner has raised concerns after the death of an “exhausted” NHS doctor who overdosed following his ninth consecutive 13-hour shift.
Dr Naeem Ahmed was found slumped in a chair inside the registrar room at Poole Hospital in Dorset on June 21, 2025. Two syringes and a half-empty bottle of Jameson whiskey were discovered nearby.
The 50-year-old consultant in anaesthesia and pain medicine had just finished his ninth straight 13-hour night shift, in addition to extra hours he had worked during the day.
Despite the punishing schedule, Dr Ahmed’s clinical decision-making during his final shift was described as “faultless”. Concerns were only raised afterwards, when another doctor was unable to find him for handover.
Dr Ahmed, who also ran a private practice, was later found dead after staff forced entry into the anaesthetist’s on-call room. He was pronounced dead at the scene.
Toxicology tests later showed he had taken the strong pain medication fentanyl. Alcohol was also detected at 44mg per 100ml of blood, about half the drink drive limit.
Now, Rachael Griffin, Dorset Senior Coroner, has written a Prevention of Future Deaths Report outlining the dangers of overworked doctors.
Mrs Griffin noted there is no legal requirement for NHS doctors to inform their trusts of their private work patterns, or vice versa.
A coroner has issued a warning after Dr Naeem Ahmed overdosed after his ninth 13-hour shift in a row working
She also pointed out NHS systems for job planning and rostering do not take into account the ‘accumulative workload across employers’.
As a result, the coroner said, this could lead to ‘continuous periods of working without rest which could put both NHS patients and doctors’ lives at risk’.
Mrs Griffin, whose report has been sent to the Minister of State for Health and the Chief Executive of NHS England, said: ‘The review and the coronial investigation revealed that Naeem died whilst working the 9th shift in a run of 11 night shifts for UHD (University Hospital Dorset Trust) which began on 12th June 2025.
‘In June 2025 he undertook clinical work for more than one provider on the same calendar day on different occasions, and on one occasion he undertook daytime work for an external provider before commencing a resident overnight shift for the Trust later the same day.
‘The review also identified that trust systems for job planning, rostering, appraisal, and secondary employment operated independently and were not designed to provide an integrated view of timing, sequencing, or cumulative workload across employers, whether over short periods or across an annual cycle.’
She added: ‘Whilst UHD have undertaken work to resolve this issue, I am concerned that this practice exists at other Trusts in England and Wales and could lead to fatigue and fatal outcomes to patients and doctors.’
In June, Mrs Griffin concluded Dr Ahmed died as a result of misadventure, determining he had not intended to end his life.
She noted there was no evidence to suggest his working pattern was a causal factor in his death and said he worked that way by ‘choice’.
Dr Ahmed was found dead in the anaesthetist’s on-call room in Poole Hospital, Dorset, with two syringes and a half-empty bottle of Jameson whiskey nearby
But the inquest did hear how Dr Ahmed began drinking and taking fentanyl as a ‘mental crutch to help calm his mind’.
His wife, Dr Laura Ahmed, also theorised how a lack of sleep potentially impacted her husband.
At the time of his death, Dr Ahmed had a private practice and had a flexible work pattern at the hospital that involved doing a lot of ‘challenging’ work – mainly night shifts, long weekends and trauma lists.
This allowed him to travel to Pakistan several times a year to help his elderly parents but his wife said the work pattern was ‘definitely starting to get to him’.
The couple had been married 23 years and had three children together. She said he was kind, patient and detail orientated.
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She said he drank alcohol away from work but said he would not drink if he had work the next day.
She said: ‘He admitted to having perhaps overbooked his two or three months, I think he was exhausted, physically and mentally.’
Dr Laura Ahmed added the fact her husband used drugs and alcohol in the hospital was ‘concerning’.
Dr Guy Titley, anaesthetic director at the hospital, said Dr Ahmed had a ‘unique job plan’ which allowed him to travel to Pakistan and the flexibility also suited the NHS trust as it helped them fill gaps at awkward times, like Christmas and Bank Holiday weekends.
He said: ‘I encouraged Dr Ahmed to spread his flexible work over the year and tried to encourage him to take a more conventional approach but he was adamant it suited him.
‘We agreed to review the situation if it changed.
‘This year he was very keen to work through his hours so he could return to Pakistan in September. He volunteered for many shifts between April to June, which was queried by the rota maker.
‘He was adamant this pattern of work was in his best interest.’
Dr Titley reviewed a number of Dr Ahmed’s cases over the six months before his death.
He said: ‘There were no indications his clinical work was at fault. On that last shift Dr Ahmed’s clinical decision making was faultless. There were no episodes of concern. His clinical record was blemish free.’
Dr Hannah McPhee, an on-call consultant who worked with Dr Ahmed on his final shift, was called in to assist in the early hours of the morning.
She said his decision-making was ‘as I would expect’.
Dr McPhee said: ‘He showed good situational awareness. Whilst we were waiting for ITU I asked about his job plan and whether it was working for him.
‘He said he did not feel it was entirely a choice as he had children who needed him as well as elderly parents in Pakistan. He said he finds it hard to do one or two night shifts and then return to days, he prefers to do a run of them. He sounded pragmatic.’
When she left she said she had ‘no doubt he expected to work the following night’.
Dr Peter Wilson, chief medical officer at University Hospitals Dorset, also gave evidence about the independent review carried out after Dr Ahmed’s death.
They reviewed the fentanyl stock and could not find any missing doses.
He said the Trust’s policies around the dispensing of controlled drugs has now been strengthened, as well as the policies around secondary employment and flexible working.
They have introduced job planning consistency panels to review doctors’ work plans and three-monthly well-being checks.
Dr Wilson added Dr Ahmed’s death had ‘sent shockwaves throughout UHD community’.
He said: ‘Everyone I have spoken to has talked about him as a well respected and well liked colleague. His death has caused huge heartache.’
University Hospitals Dorset had a controlled drugs policy at the time to ensure drugs are checked and monitored properly, signed out and any not administered are then disposed of properly and documented.
Neither the police nor the hospital could establish where Dr Ahmed got the fentanyl from.